Individualised care plan

Quality Statement 6

Before a patient with an acute coronary syndrome leaves the hospital, they are involved in the development of an individualised care plan. This plan identifies the lifestyle modifications and medicines needed to manage their risk factors, addresses their psychosocial needs and includes a referral to an appropriate cardiac rehabilitation or another secondary prevention program. This plan is provided to the patient and their general practitioner or ongoing clinical provider within 48 hours of discharge.

Purpose

To ensure that patients with an ACS have an individualised care plan before they leave the hospital.

For consumers

Before you leave the hospital, your doctors and nurses discuss your recovery with you. They help develop a plan with you that sets out:

  • What changes you may need to make to your lifestyle
  • What medicines you may need to take
  • What rehabilitation clinic or prevention service you are referred to.

You and your regular general practitioner get a copy of this plan within two days after you leave hospital.

For clinicians

Develop an individualised care plan with each patient with an ACS before they leave the hospital. The plan identifies lifestyle changes and medicines, addresses the patient’s psychosocial needs and includes a referral to an appropriate cardiac rehabilitation or other secondary prevention program. Provide a copy of the plan to the patient and their general practitioner or ongoing clinical provider within 48 hours of discharge.

For health service organisations

Ensure that processes are in place so that clinicians can develop an individualised care plan with patients with an ACS before they leave the hospital, and provide the plan to each patient and their general practitioner or ongoing clinical provider within 48 hours of discharge. 

For consumers

Before you leave the hospital, your doctors and nurses discuss your recovery with you. They help develop a plan with you that sets out:

  • What changes you may need to make to your lifestyle
  • What medicines you may need to take
  • What rehabilitation clinic or prevention service you are referred to.

You and your regular general practitioner get a copy of this plan within two days after you leave hospital.

For clinicians

Develop an individualised care plan with each patient with an ACS before they leave the hospital. The plan identifies lifestyle changes and medicines, addresses the patient’s psychosocial needs and includes a referral to an appropriate cardiac rehabilitation or other secondary prevention program. Provide a copy of the plan to the patient and their general practitioner or ongoing clinical provider within 48 hours of discharge.

For health service organisations

Ensure that processes are in place so that clinicians can develop an individualised care plan with patients with an ACS before they leave the hospital, and provide the plan to each patient and their general practitioner or ongoing clinical provider within 48 hours of discharge.